Collaboration in Focus

How would you characterize the state of collaboration and competition between dermatologists, plastic surgeons, facial plastic surgeons, and oculoplastic surgeons?

Marc D. Brown, MD: Quality care and patient safety are top of mind for all of our specialties. Although there is competition, we often collaborate where our respective specialties intersect, and we are all aligned to educating the public about the dangers and risks that come with seeking untrained providers. We are united in sharing the message that cosmetic procedures are medical procedures and medical training matters.

George Hruza, MD: Dermatologists respect the skills and expertise of our colleagues. We all have training that allows us to excel in certain areas of aesthetic medicine and have skills that complement each other. Many of the minimally invasive procedures that we offer our patients have been developed by dermatologists in collaboration with our colleagues. In fact, it is not unheard of for a dermatologist and a plastic surgeon to be in practice together, and as we know, Botox for aesthetic procedures was pioneered by an ophthalmologist and a dermatologist—husband and wife Jean and Alastair Carruthers.

I think more collaboration is always a good thing. Most physicians receive very little dermatology training in medical school. Many skin issues that patients consider to be cosmetic or that appear within the treatment area might actually be a skin cancer or other serious condition. A strong collaboration with a dermatologist can help ensure concerning skin issues get an accurate diagnosis and treatment.

Mary Lynn Moran, MD: Our organization is very open to collaboration with other core specialties. We share the same goal, which is to advance the art, science, and safety in the care of our patients. As a result of the growth of our industry, there is increasingly more overlap. We all have our unique perspective as a result of the focus of our training. With that comes a depth of knowledge that we can collectively leverage to constantly improve what we do and how we approach our craft. We have far more to gain than to lose by not reinventing the wheel.

Innovation happens when you are open to new ideas. We are increasingly working together to help improve safety and with joint educational efforts and legislative action aimed at protecting the public. More collaboration will benefit our profession as well as our patients. Collective unified efforts are far more powerful.

Thinking historically about collaboration, what has changed for the good? Have you seen any negative changes?

Dr. Moran: Aesthetic medicine has grown exponentially, and information sharing via digital communication has changed everything. In the past, collaboration happened via live meetings, visits, phone calls, or published literature that was sent by mail. Now it happens instantaneously. The negative side of digital information is that it is available to absolutely everyone. That has led to increased competition in a field that used to be practiced by those with advanced training. Competition can sharpen turf battles. We need to keep in mind that our biggest competition isn’t the core professional down the road; it is the person who isn’t trained or bound by professional ethics claiming to offer the same services for half the price.

Dr. Brown: Communication channels have improved, resulting in cooperative projects. For example, “Clinical Practice Guidelines: Reconstruction After Skin Cancer Resection” was a collaborative effort with participation from ASDS, ASPS, AAD, ACMS, AAFRPS, ASOPRS and AAO-HNS. These guidelines offer a consensus direction on the process of reconstruction after skin cancer resection. Not only did this effort offer a vehicle for collaboration, it will ultimately lead to improved care and drive better patient outcomes.

Dr. Hruza: The health care system as a whole has been fragmented, presenting challenges to collaboration. On the positive side, I think we recognize that this needs to change. But we have a lot to address from enacting legislative policies that allow collaboration across state lines to EHR systems that facilitate sharing of patient information.

We have developed strong relationships with our cosmetic and plastic surgery colleagues as well as the entire house of medicine as we advocate for patient safety with legislators and regulators.

We have joined a number of multispecialty coalitions that advocate for our patients and the ability of physicians to provide optimal care for our patients. Physicians have realized the importance of working together across specialties in our advocacy efforts at both the federal and state levels.

What opportunities or challenges do you see for enhanced collaboration?

Dr. Hruza: I think technology brings great opportunities for better collaboration amongst physicians. Telemedicine is a perfect example and one that dermatologists have embraced as a way to increase access to dermatologists. It allows other physicians to more efficiently get an expert opinion on a rash or lesion that might otherwise—depending on the patient’s location and circumstances—be difficult to get.

Likewise, technology can be an impediment, and EHRs are the prime culprit. Interoperability between systems needs to be addressed before the health care system can truly become integrated.

Dr. Brown: Efforts that continue to support patient safety and quality patient care are vital for all of our organizations. Significant challenges include divergent legislative initiatives, procedure delegation, private equity, and the convoluted digital communication space where almost anyone with a social media account can claim to be an expert. Potential collaboration around these issues can serve us all well, because they impact each of our respective practices of medicine—and ultimately the care patients receive.

Dr. Moran: We haven’t even begun to tap the potential of what we can accomplish if we work together. There are tremendous opportunities to educate the public about safety, as well as to push for more measures at the legislative level. In order to do that, we need to let go of old ways of thinking about other core professions that may be left over from decades past. We also need to make more of an effort to communicate at the leadership level. I intend to do just that during my term as president.

What initiatives are underway within your organizations or across organizations to encourage collaboration?

Dr. Brown: ASDS, ASAPS, ASOPRS, and AAFPRS have a formal structure to foster collaboration—the Physicians Aesthetic Coalition. We meet regularly to discuss issues of common interest. We work to educate members on the common ground we share with other specialties while highlighting the unique roles each these respective organizations offer. An example of this is sharing industry-related news in our member communications and organization unified statements such as collective Letters to the Editor. Additionally, we often share members across organizations. Our communal membership and our leadership team support open lines of communication, reciprocal participation in meetings and partnering on projects aligned with our respective missions and goals.

Dr. Hruza: The American Academy of Dermatology reflects and respects collaboration with physicians across the spectrum of medicine. Many medical issues have a skin component and many skin issues signal a serious underlying disease or have comorbidities. The Academy is highlighting partnership between dermatologists and our peers through our SkinSerious campaign (skinserious.org), which shares stories of collaboration between dermatologists and physicians in all specialties and the impact they have had on patients’ lives.

The Academy has also been a pioneer in encouraging the adoption of telemedicine, which can enhance collaboration on patient care and increase access to dermatologists’ expertise and a strong advocate for EHR interoperability.

We are collaborating successfully with our reconstructive colleagues in several specialties to develop guideline and quality measures on reconstructive surgery after skin cancer removal. We anticipate the publication of the joint guideline early next year.

Dr. Moran: We are working with the plastic surgeons on several projects. We also co-sponsor bill proposals with other organizations.

What is your philosophy on competition from non-cores and med-spas?

Dr. Moran: My biggest concern is the lack of actual medical supervision that is so rampant in the practice of aesthetic medicine. The practice of medicine can only be performed by licensced physician or a mid-level physician extender as per the laws that regulate that activity in each state. You cannot delegate the good faith exam to an RN or other employee, even if you are a core MD. An RN can be delegated specified procedures only after the good faith exam by the MD or mid-level practitioner. It blows my mind how frequently physicians are willing to “aid and abet in the unlicensed practice of medicine.” The vast majority of medspas are not “medical” at all. Unlicensed professionals perform procedures with little to no oversight. There are no good faith exams performed before medical procedures are performed on patients. Physicians need to understand that any harm that is done to patients at medspas under their license is their liability and their responsibility.

Dr. Brown: ASDS supports direct on-site supervision of non-physician providers by a qualified physician with clear and transparent communication to patients about who is providing care. The goal is to ensure quality care. Our newest model legislation defines both “medical spa” and “medical director,” supports on-site supervision, and offers options enabling clauses to include additional education requirements, notification if a physician is not on-site, and mandatory adverse event reporting to the FDA.

Dr. Hruza: The American Academy of Dermatology’s position is that any procedure that can cause biologic change or damage to living tissue should be performed by an appropriately trained dermatologist or a non-physician clinician under direct onsite supervision of a dermatologist. In instances where onsite supervision is not possible, a dermatologist should be immediately available for consultation if the need arises.

Some suggest that the best way to protect patients is to open education to all those who perform aesthetic procedures: “let them learn from the experts.” How do you react to that?

Dr. Hruza: As physicians we clearly believe in education. Board-certified dermatologists dedicate a decade or more to obtaining the education needed to practice dermatology and then spend our lives honing and developing our knowledge and skills.

All those offering patient care should have training commensurate with their licensure and experience and the complexity of procedures and treatments for which they are tasked. Anyone doing these procedures holds a patient’s health and sense of well-being in their hands. It’s an enormous trust and one that comes with serious study and not just a single course.

Dr. Moran: I don’t think that you can learn to do what we do in a weekend course or on the Internet. A little bit of knowledge is a dangerous thing. It takes years of training and experience to understand the nuances and risks of most aesthetic procedures.

Dr. Brown: Aesthetic procedures involve diagnosis, treatment, or correction of human conditions by any means, methods, devices, or instruments—this is the definition of the practice of medicine. Expertise requires both educational training and mentoring experiences. Board-certified dermatologists possess 12 years of medical education, more than 15,000 patient training hours, and certification from their state’s medical board. This combination is what best protects patients and enables board-certified quality medical care. To truly become an expert is to complete medical school, residency, fellowships and mentorships; allowing all types of providers to attend continuing education courses does not replace a medical education.

What tips do you offer your members in terms of how to credential themselves and help patients recognize the importance of those credentials?

Dr. Brown: ASDS members are encouraged to share our patient education efforts that help the public understand who is wearing the white coat. ASDS has an enduring national branding campaign that reinforces the importance of seeing a board-certified dermatologist. The campaign shares ASDS members’ medical training, data from the ASDS procedure and consumer surveys to reinforce member expertise, as well as research findings on increased adverse effects from non-physician providers. ASDS supports transparency in medical advertising and direct-to-patient interactions disclosing level of licensure. Our campaigns strive to educate and empower patients. Patients deserve the opportunity to make informed decisions about who provides their medical treatment.

Dr. Hruza: The Academy highlights our members’ board certification and our unique training and expertise in all our communication with the public and encourages members to highlight it by using the designation FAAD: Fellow of the American Academy of Dermatology.

Dr. Moran: Our motto is “Trust your face to a specialist.” We encourage the public to make certain that the specialist they are consulting is board certified and experienced in the procedure that they are considering. We can certainly do more to educate the public about those differences. Social media offers limitless opportunity to do just that.